Medical-Surgical Nursing, 10th Ed., Lewis, Dirksen, Heitkemper & Bucher | Registered Nurse (RN) School Study Aid
Increased Intracranial Pressure (ICP) Assessment
- Change in LOC
- Headache
- Cushings Triad
- Irregular Respirations
- Widening Pulse Pressure
- Bradycardia
- Projectile Vomiting
- Abnormal Pupils
- Papilledema
- Posturing
Level of Consciousness: Descriptive guide for Glasgow Coma Scale
- Conscious
- Confused
- Delirious
- Somnolent
- Obtunded
- Stuporous
- Comatose
Mannitol (Osmitrol)
- Osmotic Diuresis
- Reducing Intracranial Pressure
- Reducing Intraocular Pressure
- Renal Failure Prophylaxis
- Edema
- Fluid and Electrolyte Imbalance
- Avoid Use in Cardiac Patients
- IV Administration
Increased Intracranial Pressure (ICP) Interventions
- Elevate Head Of Bed
- Foley Catheter
- Mannitol (Osmitrol)
- High Dose Barbiturates
- Passive Hyperventilation
- Dexamethasone (Neoplasm or Infection)
- Neuro Assessment
- Maintain Normal Temperature
- Avoid Activities That Increase ICP
- Intracranial Monitoring System
Glasgow Coma Scale
- LOC Assessment
- Score of 3 to 15
- 8 or Less = Coma
- Eye Opening
- Verbal Response
- Motor Response
Diazepam (Valium)
- Anxiety
- Seizures and Status Epilepticus
- Muscle Spasms
- Alcohol Withdrawal
- Dizziness/Vision Changes
- Confusion/Amnesia
- Urinary Incontinence
- Behavioral Changes
- Respiratory Depression
- Flumazenil (Romazicon)
- Fall Precaution
- Do Not Stop Abruptly
Traumatic Brain Injury Assessment
- Change in LOC
- Personality Changes
- Amnesia
- Increased Intracranial Pressure
- Diplopia
- Posturing
- Basilar Skull Fracture
- Halo or Ring Sign
- Intracranial Bleeding
Types of Head Injuries
- Open Head Injury
- Linear Fracture
- Comminuted Fracture
- Depressed Fracture
- Open Fracture
- Basilar Skull Fracture
- Closed Head Injury
- Coup and Contrecoup
- Brain Contusion
- Concussion
Seizure Precautions
- Reduce Environmental Stimuli
- Identify Triggers
- Aura
- Pad Side Rails
- Bed Lowest Position
- Oxygen and Suction Available
- Monitor Therapeutic Drug Levels
Hydrocephalus
- Increased CSF in Ventricles of Brain
- Signs of Increased ICP
- High Pitched Cry
- Irritability
- Opisthotonus
- Increased Head Circumference
- Bulging Fontanel
- Setting Sun Sign
- Seizure Precautions
- Elevate HOB
- CSF Shunt
Meningitis Assessment
- Nausea and Vomiting
- Fever
- Nuchal Rigidity
- Severe Headache
- Purpura
- Seizures
- Photophobia
- Opisthotonus Position
- High-Pitched Cry
- Bulging Fontanel
Meningitis Interventions
- IV Antibiotics
- Dexamethasone
- Analgesics
- Antipyretics
- Closely Monitor for Increased ICP
- Bed Rest
- Preventative Vaccinations
- Droplet-Airborne Precautions
Penicillin
- Weakens Cell Wall
- Gram-Positive Infections
- Prophylaxis
- Pain at IM Injection Site
- Allergic Reaction
- Skin Tests
- Allergy ID
- Medication Education
Cephalosporins
- Starts with "Cef-"
- Bactericidal
- Gram-Positive and Gram-Negative Infections
- Allergic Reactions
- Thrombophlebitis
- Bleeding
- Renal Impairment
- Avoid IV Calcium with Ceftriaxone
- No Alcohol
Vancomycin
- Inhibits Bacterial Cell Wall Synthesis
- Serious Gram-Positive Infections
- Nephrotoxicity
- Ototoxicity
- Red Man Syndrome
- Thrombophlebitis
- Culture Samples First
- Infuse IV Over 60 Minutes
- Take Around the Clock
Ampicillin and Amoxicillin
- Aminopenicillin
- Broad Spectrum Penicillin
- Gram-Positive and Some Gram-Negative Infections
- Rash
- Diarrhea
- No Effect Against Staph Aureus
- Often combined with Beta Lactamase Inhibitor
- Allergic Reaction